I struggled breastfeeding my first child and had to stop just a few days after we left the hospital. I really want to breastfeed my second child successfully but feel like I will need the right kind of help.

Breastfeeding has always been one of those things that has been near and dear to me. As a mother of four breastfed children (albeit a few years ago now), a NICU nurse for 15 years, and presently a Pediatric Nurse Practitioner for 10 years, I feel that I have some of my own personal wisdom and insight about the whole topic of breastfeeding. Breastfeeding is one of those things that obviously only a mother can do! Its success not only provides your baby with the most nutritionally ideal food source but creates the groundwork for mother-infant bonding.

It has been my experience that many mothers that were not afforded the supportive environment in the early days of breastfeeding, in many circumstances did not progress to continued breastfeeding with their infants beyond the newborn period into the weeks and months of infancy. Unfortunately many of these women go on to tell me that they regret that they weren’t able to do so. As a pediatric practitioner, I believe that if we make great efforts in those early days and work with moms and their newborns, breastfeeding can and will be established.

Here at Milestones Pediatrics and Adolescent Care we want to make breastfeeding our number one priority for those moms who choose to nurse their infants. Our RN Brenda Knighton and I will take the time to work with you and your newborn to acquire the knowledge and skills to become a success. Breastfeeding, although very natural, is not an instinct your baby is born with. Newborns have the natural instinct to suck and root but require our help to latch on and suckle at the breast. Moms need to be familiar with optimal times in the baby’s wake and sleep cycles to offer their babies the breast. Signs of hunger cues occur long before a baby is crying and frantic to be picked up. In fact, waiting until this stage to breastfeed is likely to be terribly frustrating for both mom and babe. A baby will first show signs of stirring by their more rapid eye movement noticed while they are sleeping. Next they may start opening their mouths, turning their heads and sucking on the hands or fingers. A babe put to breast at this stage is much more likely to have a better outcome with the whole experience. A mother needs to make sure that she has a very comfortable chair in which to nurse her infant. Ideally a chair with good back support and one where mom’s feet easily rest on the floor. Most nursing mothers will also need a supportive pillow or “boppy” to allow their tiny newborn to be positioned horizontally at a height that is level with their nipples. Occasionally an extra rolled blanket may also be needed.

From my experience in those early days of breastfeeding, the cross cradle hold allows for mothers to more easily guide their infant’s head while also supporting their breast at the same time, so it is a good position to choose for breastfeeding. The newborn should be positioned with their chest facing their mother’s chest , skin to skin contact is ideal and a loose blanket can be used to ensure that their baby is warm but not too bundled and sleepy at the breast. Expressing a little breast milk affords the baby the taste and smell of mom’s milk. By gently touching your baby’s lips with your nipple, it will stimulate your baby to open his mouth. When baby’s mouth is wide open, guide your infant’s mouth towards your nipple using your hand support at the back of your infant’s head. An adequate latch can be seen when your baby’s upper and lower lips are flanged and much of the areola for most women is in your baby’s mouth. A good indication that your babe is getting your breast milk is demonstrated by a “rocker-like” sucking motion interspersed with pauses and audible swallowing. Ideally, they should actively suck for 10-20 minutes on each breast and your baby should seem full and satisfied. After burping your baby and putting yourself back together, enjoy the sweet satisfaction of knowing your beautiful bundle of joy has received the best nutrition possible.

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My 15 month old isn’t talking like his cousin, I’m worried

Just like other developmental milestones, there is a lot of variability in speech development from child to child. Some developmental milestones have more variability that others. For example, I’ve seen perfectly healthy children walk as early as 9 months and as late as 18 months. On the other hand, the range I might expect for sitting up on his own would be somewhere between 6-10 months (some chubby babies struggle a bit). In addition to considering the ranges of normal for any given developmental milestone, we also look at milestone categories. For example, when assessing a child’s fine motor skills, even if she doesn’t scribble on paper like I would expect at 15 months, I would be reassured by seeing her drop a raisin in a bottle or stack a couple blocks. Perhaps she simply hasn’t seen others scribble much to know what to do. On several occasions I have seen a child do in the office what her parents didn’t know she could do.

Speech is no different from other milestones in how I assess a child. I really like to think more in terms of communication than speech, because the word “communication” encompasses a broader exchange of information. When your newborn cries, he may be telling you he is hungry. When your 2 month-old reciprocates your smile, she is telling you that she acknowledges your presence and gets a good vibe from you. When your 2 month-old coos or your 6 month-old says “ga ga ga”, he’s revealing his feelings and emotions (simple as they may be). When your 10 month-old points at something and looks at you, she is telling you “I’ve seen something that grabs my interest and I want you to see it too!” When you put on a stern face and tell your 11 month-old “no”, her curled lips say “I understand the negativity and I’m ashamed”.

The actual formation of intelligible words is really a very small part of our language assessment. In fact, it is probably the least of my concerns when assessing a toddler. So what is my biggest concern? It is whether I see the building blocks for language development.   If I see all the prerequisites there but the child simply isn’t saying real words in the language spoken at home, I usually can predict a good outcome. The prerequisites I want to see are as follows.

1.  Does the child have an interest in social interaction? Without that interest language development will be a challenge. Let me give a couple of examples. Have you ever talked to a 2-4 month old baby and the baby waits for you to finish talking, then coos or babbles? You go on back and forth that way. Likewise, you play pat-a-cake with your 10 month-old and he laughs and tries to imitate your hand clapping. Sometimes interest in social interaction can manifest as pretend play. Your 11 month-old pretending to talk on the phone, for example. Similarly, your 16 month old scribbling on paper and bringing it to you in hope of receiving praise for her fine work. These examples might not be seen in a child who will be ultimately diagnosed with speech delay and autistic spectrum disorder.

2.  Does the child use non-verbal forms of communication, like gesturing or sign language. Gesturing examples might include pointing to things of interest, clapping hands when happy, waving bye bye, shaking (“no”) or nodding (“yes”) the head, frowning, etc. Some children are taught sign language at a very young age and can communicate in this manner well before their verbal skills mature. I often recommend this in a late speaking child who gets frustrated (with resultant temper tantrums) by his inability to express himself.

3.  Does the child babble or speak gibberish? While a toddler who speaks fluent gibberish is certainly amusing, the gibberish is an excellent indicator that he gets the gist of language. Always a reassuring sign.

4.  Does the child seem to comprehend language. It could be comprehension of sign language or spoken language. If a 15 month-old goes and gets her shoes when asked, that is a good sign.

5.  Is the child’s hearing OK? A hearing deficit always should be considered in a speech delayed child. We will typically send them to an audiologist to get specialized testing for young children (similar to the newborn hearing test they had). Deafness can either be congenital (present at birth) or develop later. Thus, a normal newborn hearing test does not exclude hearing loss as a potential cause of speech delay.

If all of these prerequisites are in place, then I will often take a conservative approach of either watchful waiting or referral to a speech therapist for a little extra help. The child will usually have a word “explosion” soon enough. If there is suspicion of autism or other general developmental delays, more intensive early intervention services are needed.

One final note on children in bilingual families.  Two languages at home do not confuse children and do not cause speech delay.  I expect the child in the bilingual home to have language skills as advanced as they would have in a monolingual home.  If an 18 month-old child in a monolingual home speaks, say, 30 words, that same child in a bilingual home would probably speak 15 words in one language and 15 in the other.

Does my child really have ADHD or is medication being pushed on him

I often have parents coming to me with behavioral or academic concerns about their child.  Sometimes both.  Some make it very clear to me, unabashedly, that they are looking for medication as an answer.  Others make it clear to me that they are not exactly comfortable with the idea of putting their child on medication but are open to it if there is no other solution  The last group are the parents who do not want “unnatural” medications as a solution, but are open to more holistic medications or methods to help their child’s problems.

 

Which is the right approach?  Which is the better parent?  There is no one-size-fits-all approach for every child, and the overwhelming majority of parents have their child’s best interests at heart.  It is incumbent upon parents, though, to educate themselves about ADHD from reliable sources and to work with the pediatrician and educators to arrive at the best solutions for their child.  I am quite sure that I am speaking for most pediatricians when I say that our goal is not to steamroll parents into stimulants for their child.  

 

There are very good reasons to address and manage ADHD

Studies suggest that ADHD left unmanaged leads to a higher risk of dropping out of school, drug abuse, and other high risk behaviors.  Think about that impulsive 8 year-old child who does wheelies down the middle of the street and shoots rubber bands in class.  Imagine this child being scolded day and night because he doesn’t stay on task or he forgets what you tell him to do.  Other kids may not like him much because he is always getting in their space, interrupting them, or messing up the group project.  Imagine those D’s coming back despite the frustrating 3 hours you and he spent doing 45 minutes-worth of homework.  He now hates school because he isn’t getting much time to play outside and the brain drain from reading even 2 paragraphs is unbearable.  He is so used to not following what is going on in class that he thinks it is because he’s not smart enough to understand.  His self-esteem is shot.  Now here is the scary part; imagine this child 10 years later with access to cars and mind-altering substances.  

 

This 8 year-old has combined-type ADHD with both inattention and hyperactivity.  Some kids with predominantly inattentive type ADHD may not be as rowdy, but they can suffer the same fate as this 8 year-old in many ways.  

 

Is ADHD a real disorder or just kids being kids?

ADHD is a real disorder with demonstrable differences in how the brain functions.  Like most disorders, there is a mix of genetics and environment.  Decades ago scientists used to argue over what is more important, nature or nurture.  Some of you probably have heard of those studies of identical twins raised in different environments.  We now know that nature and nurture are not mutually exclusive.  Environment can actually cause changes in genetics.  Some of the environmental factors most of you know well, like carcinogenic toxins.  But did you know that our experiences can cause changes in our genetics?  That’s right, our experiences.  Genetics is not only about the genes we have when we are born, but also about which genes are active and how active they are.  For example, paleontologists believe that dinosaur DNA is alive and well in today’s modern birds.   Birds are not dinosaurs because the genes that would make them look and act like dinosaurs have been turned off over time; but they are still there.  Our experiences can actually affect activity or expression of our genes.  

 

So while there are clearly some ADHD-causing genes, as evidenced by a higher incidence within families, there are environmental factors that affect how these genes are expressed.  What are some of these factors?  Premature birth, maternal smoking during pregnancy, and alcohol exposure in the womb are a few well-known factors.  However, these have existed for centuries, so why do we seem to be seeing more ADHD today than, say, 100 years ago?  There are a lot of theories but nothing has been definitively proven.  Food additives,  refined sugars, and food allergies have all been theorized but remain unproven in studies.  Screen activities like TV and video games seem to be associated with increased inattention, however it really isn’t clear from studies whether screen activities cause ADHD or if kids with ADHD just tend to want to watch TV more.  

 

I have never met a child who didn’t have some inattentiveness or some degree of hyperactivity at times.  In fact, I would guess that there are benefits to that in childhood development.  If kids were so focused on one thing at a time, they might expose themselves to fewer activities or see fewer things that enrich their development.  Without some degree of hyperactivity perhaps they wouldn’t get the exercise they need.  What separates the child without ADHD from the child with ADHD is that the former’s inattentiveness and hyperactivity is not to such an extent that it causes significant academic and social problems.  

 

A very common scenario I have encountered in my practice is as follows.  Parents are separated and mother brings child in for an ADHD evaluation.  Her son, Johnny, is missing recess at school on a pretty regular basis for disciplinary reasons, grades are poor, homework time is torture for both her and him, he has few to no friends, and he often tells her “I can’t do this” or “I’m stupid”.  Mom  has to constantly redirect his attention for the simplest of tasks like setting the table or picking up the clothes on his room floor, and admits that there is a lot of yelling involved.  When Johnny goes to his father’s house on weekends they play video games together (he concentrates very well on that) and generally do a lot of fun activities where he can “just be a kid”.  Mother has come to the realization that he needs to be on medication, while father thinks that is hogwash and Johnny is a normal kid.  

 

Johnny clearly experiences academic and social dysfunction as well as poor self-esteem.  Whether he has ADHD as the root cause or not, there is a problem here that needs to be addressed.  Getting into constant trouble at school, poor social relations, and being unable to play outside much after school because he and his mother are glued for hours to the kitchen table doing 30 minutes-worth of homework is not “a kid being a kid”.  

 

I typically explain to Johnny’s father that my goal is not to turn Johnny into a model child.  I don’t want to take away his free-spiritedness and I don’t want to turn him into an unhappy zombie.  In fact, in the beginning I don’t even know whether ADHD is the diagnosis.  He may have an entirely different problem, or he may have ADHD and other disorders combined.  There are parental and teacher screenings I need to review.  I need to look into other possible diagnoses like learning disabilities, cognitive disabilities, autistic spectrum disorder, depression, and anxiety.  Is Johnny having quality sleep (sleep disorders can definitely mimic or worsen ADHD symptoms)?  I am not a pawn for a pharmaceutical company, but I will recommend whatever therapeutic modality I believe will suit Johnny’s best interests for quality of life now and 30 years down the road.  If it is truly ADHD, then medication and behavioral modification together are effective.  If there are clues that Johnny has more than just ADHD, psychoeducational evaluations, sleep studies, or even psychiatry referrals may be needed.   

 

My child’s temperature is 103, should I be worried?

Fever occurs when the brain orders the body to raise its temperature in response to infection, injury, or other conditions. 

Just as your furnace works harder when you raise the thermostat setting in your home, the body shivers, the heart races, and the blood vessels constrict in an attempt to raise the body temperature.  Fortunately for humanity, a healthy brain does not set the body’s thermostat to dangerously high levels (or we would have been extinct long ago!). 

Fever is different from hyperthermia.  Hyperthermia is a dangerously elevated body temperature that is not under the body’s control.  This can happen in the person running 4 miles on a 100 degree day, or the infant wrapped in 4 blankets on a warm day.

When we deal with an infection, our concern is not the fever itself but the cause of fever.  The fever is not the enemy just as the check engine light on your car’s dashboard is not the root of the car’s problem. You can cut the power to your car’s dashboard to make the light go off, but there is still a problem in your car’s engine. The following are conditions associated with fever that should prompt you to call us immediately.


1. Fever associated with change in mental status, stiff neck, severe headache, difficulty breathing, new rash, new limp, or signs of dehydration.


2. Any infant less than 2 months of age with fever 100.4 or higher. (could be a serious bacterial illness)


3. Fever in a child who cannot adequately fight infection.  Examples are children with diseases like cystic fibrosis, sickle cell disease, HIV, diabetes, and lupus.  Also included are children on medications like chemotherapeutics and oral steroids (not inhaled).


4. Fever in a child who recently had surgery.

5. Fever with significant abdominal pain (could be appendicitis)

It is important to remember that treating fever does not treat the illness.  We “treat” fever mainly for patient comfort.  The best way to bring fever down is with an antipyretic medicine such as Acetaminophen (Tylenol®) or Ibuprofen (Motrin®), which lower the body’s thermostat setting.  Do not use Aspirin, as this can cause a dangerous brain and liver condition called Reye Syndrome.  Cool or even room temperature baths are not a good idea because they only temporarily bring the temperature down without lowering the thermostat setting.  Imagine leaving your doors open on a cold, blistery day.  Your furnace will just work harder trying to get that temperature back up!  Your child may feel like she is submerged in ice water.

Febrile seizures are seizures that occur only in the presence of fever.  They occur in some susceptible children aged 6 months to 6 years but are generally harmless (but very scary to you if you witness it).  Her whole body will shake, jerk, or stiffen and you may see her eyes roll back. Sometimes I have seen kids get chills that look like a seizure but really are not. After the seizure he will appear very tired and “out of it” for several minutes.

Febrile seizures result from a rapid rise in temperature, and often times the seizure has begun by the time you recognize that your child has fever.  If it does happen, roll him to his side on the floor to decrease the chance that he bites his tongue and to keep his airway open. If it is his first seizure with fever, you are best off calling 911 because at this point we don’t necessarily know that it is a febrile seizure. Then put your hand on his shoulder to make you feel better and wait for it to end and for the ambulance to arrive. They usually end within 5 minutes but occasionally may last much longer. Once we know your child gets febrile seizures and he has a brief one (less than 4 minutes), you don’t necessarily need to call 911, just call us. If it lasts longer than 4 minutes, do call 911.

If your child is developmentally normal, chances are he will outgrow febrile seizures and not go on to have epilepsy. If he does have any kind of developmental abnormality, the chance of becoming epileptic is much higher.

I think my child has ringworm, but he takes baths every day. I’m so embarrassed.

Ringworm is a fungal infection of the skin and/or nails. There are no worms, you’ll be happy to know. It can be present anywhere on the skin, including the scalp, groin (jock itch), and toes (athlete’s foot). It gets its name from the ringed rash it causes on the skin. Ringworm is NOT a sign of bad hygiene; anyone can get it. The fungus can be transferred from person to person directly (e.g. wrestlers) or indirectly (from shared combs, clippers, shower floors, etc.). Pets can also be a source.

The rash is typically itchy and unsightly. It may start off looking like a pimple and progress to look like a pink coin on the skin. On the scalp it may show as a scaly, itchy rash with thinning of the hair in the involved area. Between the toes you may see redness and cracking. On the nails fungal infections may cause thickening and discoloration.

Fungal infections on the skin usually respond to over-the-counter topical anti-fungal medications like Lamisil® or Lotrimin®. However if it is the first time a child has such a rash, it may be a good idea to have it seen at the office, as there are other rashes that can mimic ringworm. Fungal infections on the scalp and nails usually require oral medications. Scalp fungal infections may also benefit from certain shampoos (e.g. ketoconazol or selenium sulfide), which your doctor or nurse practitioner can discuss with you.

My baby spits up a lot. Do I need to change her formula? Is it the iron? Is she getting enough to eat?

All babies spit up at one time or another, some more than others. 

We all have a sphincter between our esophagus and stomach that loosens when food and liquid go down, but tightens while the stomach churns the food to prevent everything from coming back up. Infants tend to have a sphincter that is a little loose, resulting in spit-ups. There are other reasons babies might spit up. Pressure on the belly (many women who have experienced pregnancy can attest to this) can overcome the resistance in the sphincter and lead to stomach contents coming up. Some babies whose stomachs are irritated for whatever reason will spit up or vomit (e.g. stomach virus or formula allergy). Finally, obstruction somewhere between the mouth and intestines can also cause spit ups or vomiting.

Most spitting by babies is completely benign, nothing to worry about. If your baby is generally happy, growing well, and does not have frequent cough or gagging, nothing more than buying extra spit cloths is necessary. As the famous bib slogan says, “spit happens”. I often find that parents think their baby spit up the whole feed. That is rarely the case. Try this experiment at home. Pour 3-4 oz of water in a glass and watch it as you throw it into the sink. Then compare that to the amount of milk that comes out of your baby’s mouth.

There are some simple steps to reduce spitting. Keep your baby upright for 20-30 minutes after feeds. Decrease the volume of feeds, but increase the frequency (for example, instead of 4 oz. every 4 hours, give 3 oz. every 3 hours). Breastfeeding certainly helps as breast milk leaves the stomach and passes into the intestines more quickly than formula. If you are bottle feeding, I can promise you that iron is not the reason. Formula fed babies need the extra iron in formula (iron in formula is not as well absorbed into the infant’s body, so they need more). A low iron formula just about guarantees the infant will have anemia.

The following lists circumstances in which spitting may be concerning:

1. Is your baby unusually fussy throughout the day? (Read our section on colic in the Newborn Booklet; colicky babies tend to be fussy mostly toward evening, extreme fussiness throughout the day suggests another problem) . Does your baby seem unsatisfied after feeds? Does he/she arch her back during or after feeds? Does he/she seem hungry all the time, yet pulls back from the breast or bottle when offered. Your baby may be having severe heartburn (burning in the esophagus) and should be seen within a day or so.

2. Are the contents of the spit up green? This may be a surgical emergency; your baby needs to be seen immediately.

3. Is your baby regularly gagging, coughing, or turning blue during feeds? If so, have her seen for this. There may be an obstruction or abnormal connection between the esophagus and windpipe.

4. Are the spit ups occurring quickly after feeds and progressively more forcefully as days go by? Call your doctor or nurse practitioner, as there may be a developing obstruction in the stomach outlet called pyloric stenosis. If your baby does not appear ill or lethargic and is well hydrated (wetting at least one wet diaper every 6-8 hours, mouth looks wet, soft spot on scalp is not sinking in when you have him sitting up), an urgent trip to the emergency room may not be necessary. While this typically requires surgical correction, the surgery is not needed urgently like in the scenario with green vomiting.

5. Does your baby have an associated fever? Please refer to our fever blog.

6. Have you seen blood or mucus in your baby’s stools? This could be a sign of formula allergy or intestinal infection (if you have a pet reptile, salmonella is a concern!). Call your doctor or NP.

My child has a rash. What should I do?

My child has a rash that just appeared today. It’s spreading rapidly. Could it be chickenpox?

My baby has a rash on her cheeks and forehead. Should I put lotion on it?

Rashes are one of the most challenging diagnoses to a pediatrician. You will find that we can often tell you what the rash is not, but may not be sure what exactly it is. The reason for this is that there are hundreds of rashes, and sometimes the same cause may have different appearances from one person to the next. What pediatricians recognize very well, however, are the dangerous rashes.

Chickenpox can range from a benign to deadly illness. Once upon a time chickenpox was relatively easy to diagnose, but in this age of chickenpox vaccine the rash and overall symptoms can be so mild as to be unrecognizable. Classically the chickenpox rash starts on the forehead and scalp line, spreading to the trunk and then arms. You see a combination of pimples and blisters, which are itchy. Small infants and elderly are at highest risk for serious complications.

Probably the rash that triggers the most alarm is that from the bacteria N.meningococcus (there’s almost a yearly story about a college student who developed this, but it can happen at almost any age). Describing it on this site does not do it justice, but you can find many pictures of it on the internet, just look up “meningococcemia”.

There are many other rashes associated with dangerous conditions, but here are some simple rules to determine whether your child needs to be seen immediately or whether it can wait a day or more.

1. When you press on the rash and blanche the skin, does the rash disappear in that spot momentarily? If not, have your child seen immediately.

2. Does the rash look purple? If so, have your child seen.

3. Is your child alert and active, or does he/she appear lethargic and/or limp? If lethargic and/or limp, have your child seen immediately.

4. Does your newborn have blisters or a combination of pimples and blisters anywhere on the skin? If so, have him/her seen immediately.

5. Does your child have blisters on his skin and inside the mouth, eyes, or nostrils? Have him/her seen immediately.

6. Is the rash painful? If so, have your child seen immediately.

 

My child has a cold and hasn’t eaten anything for 2 days. What can I do?

It is quite normal for a child to have a decreased appetite when ill. If you think about it, most of us adults do not have a normal appetite when ill. People can survive a few weeks without food, so 2 or 3 days with a poor appetite poses no grave danger. Two or three days without fluids, on the other hand, can be deadly, especially if there are fluid losses from fever, vomiting, diarrhea, or excessive urination (in a diabetic or child with sickle cell disease).

Everybody, adult or child, has fluctuations in weight from day to day. We look at a child’s growth curve over an extended period of time to gauge how well he/she is growing. If we charted weight daily we would all go crazy with worry (just think how your own scale plays mind games with you)! A child who lost a pound during an illness will make up for it later, rest assured, unless there is a more chronic problem going on.

Don’t force your child to eat, but calmly offer anything healthy he/she might nibble on. Resist the urge to offer cookies and M&Ms “just to get her to eat something”; you will pay for that later. If everything is refused, don’t panic. Try again later.

Of special note is the child with vomiting and/or diarrhea. This is discussed in my diarrhea blog, but a couple quick notes here. Definitely avoid fatty and sugary food and drink as these will make the diarrhea worse. A short break (2-3 days) from milk may be worth a try, especially if the diarrhea is prolonged (e.g. 1 week or longer). Yogurt, however, tends to be well tolerated. If you are breastfeeding, definitely continue! The breast milk is beneficial. The BRAT diet (bananas, rice, applesauce, and toast) is a time-honored but often misunderstood diet. I find that parents sometimes think they should give this diet alone, but that should not be the case. While it is helpful for bulking loose stools, it is not particularly nutritious and if given alone for days can cause malnutrition. Give it in conjunction with fruits, vegetables, whole grains, and lean meats.

My child fell and hit her head. There’s a big bump on her forehead. What should I do? Do I need to go to the emergency room?

Head injuries are very common, and in considering how serious one might be, there are several factors that we need to examine.  Some of the worst looking bumps, bruises, and goose eggs pose absolutely no danger to your child’s brain at all because they are simply signs that the skin took the brunt of the injury. This is especially true on the thick-boned forehead.  In fact, if you are going to hit your head, the forehead is the best place to do it. Have you ever seen a martial artist break brick with the side or back of his head? So if I see an alert child with a giant goose egg on the forehead after running into a doorknob, I’m usually pretty darn sure he will be OK. I always joke with patients that God made kids short, light, and slow for a reason. Now the temples, on the other hand, are a bad place to hit your head. Swelling there always concerns me for the possibility of a skull fracture. I once saw a kindergarten aged child who ran into another child on the playground and had a skull fracture in the temple.

Below are some important points to consider when deciding whether you should call 911, call our office, or just head to the ER.

1. Any fall or head injury in a newborn should prompt you to call 911.  This age group is at much higher risk for bleeds in the brain than older infants and children. This is due to a soft skull and blood vessels in the brain that bleed more easily.


2. The mechanism of injury is important.  A fall off a couch (a newborn being the exception) or bumping into a doorknob or drywall is unlikely to lead to a serious brain injury, no matter how bad the swelling and bruise.   A fall from a balcony, a head injury in a car accident, a baseball pitch or line drive to the head, a fall off a bike, or an assault should be seen immediately.


3. Any infant or child who loses consciousness from a head injury, even for a moment, should be seen immediately.  When I say lose consciousness I don’t necessarily mean looks dazed for a moment. I mean out cold. If he remains unconscious for more than a few seconds, call 911 and do not try to move him as there could be an associated neck injury.


4. If there is a progressive decrease in alertness, call 911.  A way to distinguish this from just normal sleepiness at a late hour is to see if you can awaken your child and get him to respond appropriately to you.  This can be done successfully with even the sleepiest of children, but a child with a bleed inside the skull may not respond appropriately (i.e. wake up and be coherent).  It’s always a good idea to awaken her every 2 to 3 hours after a head injury to make sure she is responsive. Don’t be afraid to be annoying (or cause a little pain) in your attempt to awaken her. One of my favorite tricks is to rub the sternum (breast bone) back and forth with my knuckles. Ice to the face is another good one. If a semi-painful or annoying maneuver doesn’t awaken her and make her say “Dad, what the heck are you doing???”, call 911.

5.
If none of the above occurs but your child is vomiting please call us immediately. If we are closed take her to the emergency room as soon as possible. Vomiting 15 minutes or longer after the injury is more concerning than vomiting within a couple minutes of the injury. Young kids will often cry very hard right after a trivial injury and make themselves cough and vomit (for example after bumping their heads into a door or falling off the couch). In this situation you need not worry.

Head injuries and breath holding spells
One other interesting situation you might encounter is a breath holding spell. Some children after an upsetting event (for example brother threw a block at his head) will look like they are shocked, hold their breath, change colors, and pass out. They may even stiffen and jerk like they are having a seizure. They will come to soon enough, fear not.

Bleeding disorders
If your child has a bleeding disorder like hemophilia or ITP, please call us or take him to the ER after any head injury just to get checked out.

CT Scans
Keep in mind, that, although we recommend seeking medical attention in the above situations, that does not necessarily mean we are recommending a CT scan. In fact, most head injuries do not require a CT scan and can be properly evaluated through history, physical examination, and sometimes observation. The purpose of the head CT is to look for a bleed inside the skull that will require neurosurgery, not to diagnose a concussion. Fortunately research has given us a better understanding of which signs and symptoms suggest such a bleed, which should allow us to decrease the amount of radiation children receive from unnecessary CT scans.

Concussions
Concussions can occur with relatively minor head injuries or more severe head injuries. Nobody can really predict how bad a concussion is or how long someone will be out of activities. They are essentially a brain injury, but not the type that requires any surgery or intensive care monitoring. Kids have symptoms such as headache, light headedness, dizziness, nausea, forgetfulness, and poor concentration. If your child has had a concussion, we will recommend a period of absolute rest from exercise, media activities (TV, smartphone, video games, etc), school work, and even going out and about. Return to normal activity is a gradual process of making sure your child has no symptoms or signs each step of the way. Some of these signs may be very subtle and picked up on tests like ImPACT® (most parents of high school athletes are probably familiar with this test). While it may be frustrating to the child or parent if we seem very deliberate in allowing return to normal activity (especially sports), it is because setbacks can often cause much more severe and prolonged symptoms. We want your child to be well for the long haul, if not the big game next week.

My child has had diarrhea for two days. I’m worried about dehydration. How should I treat this?

Diarrhea is a common manifestation in many illnesses. There is no recommended treatment for most diarrheal illnesses (outside of hydration) in infants or children. Adult diarrhea medications can, in fact, be harmful to infants and children. A good option for hydration is Pedialyte®, because it contains some sugar and salts which are essential to getting fluids absorbed into the body.

The World Health Organization (WHO) has a recipe for a homemade oral rehydration solution, as follows; 1 quart water, 1 teaspoon baking powder, 1 cup orange juice, and 3/4 teaspoon table salt. Plain water will not do the trick as well. Juices alone are OK, however be weary of very sugary or syrupy juices, which can actually make diarrhea worse. If your child refuses the ideal liquids, give him/her anything age appropriate, as any fluid is better than none. Studies have shown that most children can be rehydrated very well with oral fluids, in fact with better outcomes than IV fluids. Only in rare cases are IV fluids needed, like a child who cannot tolerate fluids despite anti-vomiting medications, a child who is severely dehydrated, or a child who needs surgery. We often do prescribe anti-vomiting medications to help with oral rehydration.

Generally an infant or child having only 3-4 loose to watery stools per day is unlikely to become dangerously dehydrated if not vomiting. Each stool might have 2-3 oz of fluid loss, so that child might lose 6 to 12 oz of fluid from his diarrhea. Try to get your child to drink 2-3 oz of fluid for each watery stool in addition to what he would normally drink in a day. Some children with severe diarrhea for several days may benefit from a zinc supplement (zinc can be lost in the stool causing zinc deficiency, which in turn can make the diarrhea worse). Probiotics may also be beneficial as well. As for foods, you should encourage your child to eat the usual nutritious foods. I have, unfortunately, seen children come to the ER literally starving after 3 or 4 days of nothing but Pedialyte. Some of you may have heard of the BRAT diet (bananas, rice, applesauce, and toast). I prefer to think of it as BRAT therapy, because it should be a stool bulking supplement to other healthy foods rather than a complete diarrhea diet.
 
In the following two circumstances you should contact your child’s medical provider immediately: 

• no urine output for 8 hours or more, very dry mouth, dough like skin, dry eyes when crying, sunken-in soft spot on an infants scalp, or listlessness.
• Bloody diarrhea